Vila Monte

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced case management – legal/non-compliance visit. LPA met with Administrator (ADM) Nicholas Inneh. LPA stated the purpose of the visit. The purpose of the visit is to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on 10/23/2024. LPA discussed the non-compliance plan with the ADM to include ensuring that all staff are trained to provide resident care meeting physical, emotional, and social needs; plan for regular observation from the resident and documentation of resident functioning changes; ensuring the facility is kept clean, safe, sanitary and in good repair, addressing any signs of bed bug infestation; ensuring all incident and death reports are documented and reported to CCL per Title 22; ensuring all staff obtain a criminal record clearance and association to the facility; ensure all residents medical assessments include a TB result prior to admission; ensure all resident’s reappraisals are updated annually; ensure all meals meet dietary and physician ordered nutritional requirements, and ensuring the Administrator provides proper oversight and administration of the facility operations in alignment with Title 22 regulations. During visit, LPA toured the facility with ADM include the resident bedrooms, hallways, bathrooms, dining room, kitchen, and exterior. See LIC809-C LPA inspected 25 residents rooms with the ADM. There were no observation of bed bugs. ADM states the facility does not have any active cases of bed bugs. ADM states in June 2026, a resident reported seeing a bedbug. ADM states he inspected the resident's room but did not find any bedbugs or signs of a bedbug infestation. ADM states he sprayed/treated the resident's room. ADM states the facility inspects residents rooms twice a week for bedbugs. ADM states the facility has a pest control company that also comes out twice a month to inspect for bedbugs and rodents. LPA reviewed the pest control invoices, with the last visit conducted at the facility on 6/23/2026. During visit, LPA observed staff moping resident rooms during inspection. LPA reviewed facility 'Daily Cleaning Log' and observed today's date 6/29/2026 9AM -11PM to have a hand written check mark for all task/duties (sweeping/mopping, sanitizing, cleaning and wiping surfaces) marked as completed. ADM was advised to ensure staff are documenting completion of tasks accurately to ensure the facility is clean, safe, sanitary and in good repair at all times. LPA reviewed 3 staff files (S1 to S3). 3 out of 3 staff have current training as of 4/9/2026 to include but not limited to topics of dementia care, personal rights, medication training, assisting with Activities of Daily living (ADLs), reporting requirements & mandated reporting, food service and nutrition. ADM states staff conduct a deep cleaning of the facility at least once a month, monthly meetings are held with staff to review the above topics (cleanliness, pest control, resident's needs), and daily staff meetings are also conducted. LPA reviewed 3 resident files (R1 to R3). 3 out of 3 residents have current physician's report with TB result, current pre-appraisal, and service plans. R3 was noted to have a restricted diet. ADM states the facility is adhering to R3's restricted diet plan. The Administrator was advised regarding the importance of adhering to the facility's corrective action plan that was developed on 10/23/2024 to ensure the facility stays within compliance of Title 22 regulations. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator (ADM) Nicolas Inneh and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 29, 2026

Type of visit: Required - 1 Year

On 4/17/2026, LPA Grace Donatoi arrived unannounced to conduct the facility's required 1 year annual inspection. LPA met with Administrator (ADM), Nicholas Inneh. During visit, LPA toured the facility with ADM to include the resident bedrooms, bathroom, shower room, kitchen, hallways, dining room, and exterior. All fire exit routes were free and clear of obstruction. Medications, disinfectants, sharp objects observed locked. Facility temperature maintained at 68 degrees F. Resident bedrooms contains adequate lighting, beds, linens, dressers/closet space, and a night stand. Facility has at least 7 days worth of non-perishables and 2 days worth of perishable foods. The kitchen is equipped with 2 refrigerators which were maintained at 30 degrees F and the 2 freezer temperatures maintained at 0 degrees F. Facility has an operable carbon monoxide and smoke detector. Fire extinguishers were serviced and updated. Facility has a sprinkler system. Emergency disaster plans posted next to the exit doors. The facility has emergency flood lights in each hallway in case of a power outage. Facility has a first aid kit located in the medication room. LPA reviewed 5 resident files and 5 staff files. All records are complete and updated. No deficiencies cited today. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Apr 17, 2026

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management - Legal/Non-compliance inspection. LPA Rai met with Administrator (ADM) Nicholas Inneh and stated the purpose of today's visit. The purpose of the visit is to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on 10/23/2024. LPA Rai discussed the non-compliance plan with the ADM to include ensuring that all staff are trained to provide resident care meeting physical, emotional, and social needs; plan for regular observation from the resident and documentation of resident functioning changes; ensuring the facility is kept clean, safe, sanitary and in good repair, addressing bed bugs proactively and promptly; ensuring all incident and death reports are documented and reported to CCL per Title 22; ensuring all staff obtain a criminal record clearance and association to the facility; ensure all residents medical assessments include a TB result prior to admission; ensure all resident’s reappraisals are updated annually; ensure all meals meet dietary and physician ordered nutritional requirements, and ensuring the Administrator provides proper oversight and administration of the facility operations in alignment with Title 22 regulations. During visit, LPA Rai toured the facility to include the resident bedrooms, hallways, bathrooms, dining room, kitchen, and exterior. LPA Rai observed 2 staff members present were observed to be fingerprint cleared and associated to the facility. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. LPA Rai entered into all the resident bedrooms. All rooms are currently occupied. There were no observation of bed bugs. ADM states the facility does not have any active cases of bed bugs. ADM states a third party vendor for pest control inspected the facility on 02/10/2026 and no rodent or insect activity was noted at the facility. ADM states a third party vendor for pest control inspects the facility at least twice a month. LPA Rai observed the facility has a weekly cleaning and maintenance log for 03/01/2026 - 03/12/2026. During visit, LPA Rai observed staff cleaning resident rooms and completing the weekly cleaning and maintenance log. LPA Rai at random reviewed 2 staff files (S1-S2). 2 Out of 2 staff were provided 20 hours of training which include the follow topics: 'Assisting resident with ADLs (Activity of Daily Living)', 'Dementia Care', 'Personal Rights', 'Basic Medication Training', 'Reporting Requirements', 'First Aid', 'Emergency Procedures', 'Food Services', 'Nutrition & Hydration', 'Infection Control', 'Observing and Documenting Resident Changes', and 'Communication & Working with Difficult Behaviors'. LPA Rai at random reviewed 3 new resident files (R1-R3) who moved into the facility from June 2025 - December 2025. 3 Out of 3 files contained LIC 602 Physician's Report including TB result and LIC 624 New Admission Appraisal. All 3 residents do not have a special diet per LIC 602 Physician's Report. LPA Rai reviewed Incident Report dated 02/01/2026 for resident R4 and noted no issues. The Administrator was advised regarding the importance of adhering to the facility's corrective action plan that was developed on 10/23/2024 to ensure the facility's stays within compliance of Title 22 regulations. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator (ADM) Nicholas Inneh and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 13, 2026

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced visit for a case management – legal/non-compliance requirement. LPA met with Administrator (ADM), Nicholas Inneh. At the time of arrival LPA was greeted by 2 staff, administrator arrived at approximately 10:00 a.m. The purpose of the visit is to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on 10/23/2024. LPA discussed the non-compliance plan with the ADM to include ensuring that all staff are trained to provide resident care meeting physical, emotional, and social needs; plan for regular observation from the resident and documentation of resident functioning changes; ensuring the facility is kept clean, safe, sanitary and in good repair, addressing bed bugs pro-actively and promptly; ensuring all incident and death reports are documented and reported to CCL per Title 22; ensuring all staff obtain a criminal record clearance and association to the facility; ensure all residents medical assessments include a TB result prior to admission; ensure all resident’s reappraisals are updated annually; ensure all meals meet dietary and physician ordered nutritional requirements, and ensuring the Administrator provides proper oversight and administration of the facility operations in alignment with Title 22 regulations. During visit, LPA toured the facility to include the resident bedrooms, hallways, bathrooms, dining room, kitchen, and exterior. LPA observed some wear and tear on the building grounds. ADM stated that there are plans to renovate/remodel the facility, fix the bathrooms, floors, and parking. Page 1 of 2 LPA toured the facility with ADM and most rooms were occupied and residents were there. There are 15 room, 2 of the 15 are single occupancy and 13 are shared. The facility currently has 27 residents. There were no observation of bed bugs. ADM states the facility does not have any active cases of bed bugs. ADM provided a copy of the Clark Pest Control service report dated 12/02/25. Report stated the pest control person, did a visual check and did not notice any rodent and insect(ants, cockroaches, spiders, and bedbugs) activity. There was 1 mice caught in the food closet, replaced the glue boards and the device. They checked the exterior rodent monitoring station and did not notice rodent activity. ADM states the pest control company comes at least 2 times a month. LPA observed the facility has a cleaning and maintenance log. During visit, LPA observed staff actively mopping the floors of the facility. LPA reviewed 5 out 25 resident files and observed the files were updated and complete, including but not limited to Physician's report (LIC 602), Appraisal Needs and Services Plan (LIC 625), Admission Agreement, Personal Rights (LIC 613) and the client's personal valuable (LIC 621). LPA reviewed 2 staff file (S1 and S2). 2 out of 2 staff have current training on record from online (Relias and Community Senior Living). On 4/7/2025, ADM conducted a staff training for the following: Dementia Care - 2 hours, Personal Rights 1.5 hours, Basic Medication Training - 2 hours, Reporting Requirements and Mandated Reporting - 2 hours, Basic First Aid and Emergency Procedures 1.5 hours, Food Service, Nutrition and Hydration - 2 hours, Universal Precautions & Infection Control - 1.5 hours, Observing and Documenting Resident Changes - 1 hour, Resident's Right and Cultural Sensitivity - 1.5 hours, Activities and Social Services - 1 hours, Assisting with Activities of Daily Living (ADLs) - 2 hours, Communication & Working with Difficult Behaviors - 2 Hours. ADM has a valid administrator certificate for ARF and RCFE that would expire on 11/20/2026 (ARF) and 7/20/2026 (RCFE). The Administrator was advised regarding the importance of adhering to the facility's corrective action plan that was developed on 10/23/2024 to ensure the facility's stays within compliance of Title 22 regulations. No deficiencies were cited during today's visit based on California Code of Regulations Title 22. An exit interview was conducted with Administrator Nicholas Inneh and a copy of the report was provided. page 2 of 2 - end of reportthe state’s words, verbatim · CDSS document, Dec 9, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with Administrator (ADM), Nicholas Inneh. The purpose of the visit is to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on 10/23/2024. LPA discussed the non-compliance plan with the ADM to include ensuring that all staff are trained to provide resident care meeting physical, emotional, and social needs; plan for regular observation from the resident and documentation of resident functioning changes; ensuring the facility is kept clean, safe, sanitary and in good repair, addressing bed bugs proactively and promptly; ensuring all incident and death reports are documented and reported to CCL per Title 22; ensuring all staff obtain a criminal record clearance and association to the facility; ensure all residents medical assessments include a TB result prior to admission; ensure all resident’s reappraisals are updated annually; ensure all meals meet dietary and physician ordered nutritional requirements, and ensuring the Administrator provides proper oversight and administration of the facility operations in alignment with Title 22 regulations. During visit, LPA toured the facility to include the resident bedrooms, hallways, bathrooms, dining room, kitchen, and exterior. 3 staff members present were observed to be fingerprint cleared and associated to the facility. See LIC809-C. LPA entered into all the resident bedrooms. All rooms are currently occupied. There were no observation of bed bugs. ADM states the facility does not have any active cases of bed bugs. ADM states in July 2025 the pest control company found 1 bed bug on the mouse trap behind the refrigerator in the hallway. Upon discovery, the ADM inspected all resident beds and did not observe any beg bugs. ADM also followed-up with the residents who denied any case of bed bugs in their rooms. ADM states the pest control company last visited on 08/11/2025. ADM states the pest control company comes at least 2 times a month. LPA observed the facility has a cleaning and maintenance log. During visit, LPA observed staff actively mopping the floors of the facility. 2 staff files (S1 - S2) was reviewed. 2 out of 2 staff were provided training by the ADM and Relias on January 2025 and 04/08/2025 to include topics of assisting resident with ADLs (activity of daily living), dementia care, personal rights, basic medication training, reporting requirements, first aid, emergency procedures, food services, nutrition & hydration, infection control, observing and documenting resident changes, and communication & working with difficult behaviors. Administrator states they continue to implement regular check-in with staff every Friday for deep cleaning parts of the facility, monthly meeting with every staff, and daily meeting with the staff as part of their communication. 3 resident files (R1 - R3) was reviewed. 3 out of 3 residents is a new admissions to the facility as of June and July 2025. 3 out of 3 files contained a TB result, pre-appraisal, and progress notes. The 3 residents does not have a special diet per their physician's report. 3 resident's appraisal/needs and services plan are not completed as of today's visit (08/19/2025). A type B deficiency was cited today per Section 87467(a) - Resident Participation in Decision Making wherein 3 resident's reappraisals are not completed. The Administrator was advised regarding the importance of adhering to the facility's corrective action plan that was developed on 10/23/2024 to ensure the facility's stays within compliance of Title 22 regulations. On 08/18/2025, ADM emailed LPA Kabariti confirmation of the outstanding annual fee payment. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Nicolas Inneh and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Aug 19, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87467(a) · Plan of correction due date: Aug 26, 2025

(a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility. This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not comply with the section cited above wherein 3 residents reppraisals were not completed to indicate the individual care the resident will receive which poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 19, 2025

Plan of correction: Administrator states they will meet with each resident to go over the reaprraisals. Administrator states to submit the 3 residents reappraisals to LPA Kabariti via email by POC due date of 08/26/2025.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with Administrator (ADM), Nicholas Inneh. The purpose of the visit is to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on 10/23/2024. LPA discussed the non-compliance plan with the ADM to include ensuring that all staff are trained to provide resident care meeting physical, emotional, and social needs; plan for regular observation from the resident and documentation of resident functioning changes; ensuring the facility is kept clean, safe, sanitary and in good repair, addressing bed bugs proactively and promptly; ensuring all incident and death reports are documented and reported to CCL per Title 22; ensuring all staff obtain a criminal record clearance and association to the facility; ensure all residents medical assessments include a TB result prior to admission; ensure all resident’s reappraisals are updated annually; ensure all meals meet dietary and physician ordered nutritional requirements, and ensuring the Administrator provides proper oversight and administration of the facility operations in alignment with Title 22 regulations. During visit, LPA toured the facility to include the resident bedrooms, hallways, bathrooms, dining room, kitchen, and exterior. 3 staff members present were observed to be fingerprint cleared and associated to the facility. See LIC809-C. LPA entered into all the resident bedrooms. There were no observation of bed bugs. Staff and ADM states the facility does not have any active cases of bed bugs. LPA observed staff actively cleaning the facility to include the resident bedrooms, bathrooms, and shower rooms during tour of the facility. LPA observed the facility has completed the cleaning and maintenance log. ADM showed that the pest control company last visited the facility on 05/19/2025. LPA observed bedroom #9 is currently occupied. 2 staff files (S1 - S2) was reviewed. 2 out of 2 staff were provided training by a certified trainer to include topics of assisting resident with ADLs (activity of daily living), dementia care, personal rights, basic medication training, reporting requirements, first aid, emergency procedures, food services, nutrition & hydration, infection control, observing and documenting resident changes, and communication & working with difficult behaviors. Administrator states they continue to implement regular check-in with staff every Friday for deep cleaning parts of the facility, monthly meeting with every staff, and daily meeting with the staff as part of their communication. 3 resident files (R1 - R3) was reviewed. 1 out of 3 residents is a new admissions to the facility as of March 2025. 3 out of 3 files were completed and up to date. ADM states they do not have any residents with a special diet per the physician. The Administrator was advised regarding the importance of adhering to the facility's corrective action plan that was developed on 10/23/2024 to ensure the facility's stays within compliance of Title 22 regulations. During visit, ADM signed the LIC809-D from the annual inspection on 04/24/2025, which was inadvertently amended. A copy of the LIC809-D was provided. On 05/23/2025, LPA emailed the Licensee and ADM regarding the outstanding civil penalty payment due. This was sent to the Licensee on 10/30/2024. During today's visit, ADM was again reminded of the outstanding civil penalty payment due to the Department. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Nicolas Inneh and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 28, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's required 1 year annual inspection. LPA met with Administrator (ADM), Nicholas Inneh. During visit, LPA toured the facility with ADM to include the resident bedrooms, bathroom, shower room, kitchen, hallways, dining room, and exterior. All fire exit routes were free and clear of obstruction. Medications, disinfectants, sharp objects observed locked. Staff present are fingerprint cleared and associated to the facility. The facility has an activity calendar, laundry schedule, shower schedule, and personal rights form posted in the hallway. Facility temperature maintained at 69 degrees F. Resident bedrooms contains adequate lighting, beds, linens, dressers/closet space, and a night stand. Facility has at least 7 days worth of non-perishables and 2 days worth of perishable foods. The kitchen is equipped with 2 refrigerators which were maintained at 30 degrees F and the 2 freezer temperatures maintained at 0 degrees F. Items inside the refrigerator observed covered. LPA recommended to clean, de-clutter, and organize the kitchen and pantry. LPA did not observe any rodents or insects in the kitchen during visit. Hot water temperature in the bathroom maintained at 111.4 degrees F. Facility has an operable carbon monoxide and smoke detector. Fire extinguishers last serviced on 04/19/2024. Facility has a sprinkler system. Emergency disaster plans posted next to the exit doors. The facility has emergency flood lights in each hallway in case of a power outage. The last emergency drill was completed on 01/15/2025. Facility has a first aid kit located in the medication room. See LIC809-C. LPA reviewed 3 resident files. 3 residents records observed complete to include an admission agreement, updated physician's report, TB result, updated appraisal/needs and services plan, consent form, safeguard of personal properties/valuables, personal rights, centrally stored medication record, and cash resources. 2 out of 3 resident's has cash resources which was inspected with the ADM and observed complete. LPA observed there are no start dates on the resident's CSMR or on the medication bubble pack/bottle. LPA observed the facility is not maintaining the resident's medication administrator record (MAR) as the last input was dated on 04/19/2025 and some medications were not listed on the MAR. ADM was advised. During the medication inspection, LPA observed 1 resident was not provided their daily routine medication from 04/08/25 - 04/23/25 because the resident was out of medication. ADM states they had called the pharmacy and doctor the 2-3 days before the resident's medication ran out. ADM called the doctor during visit and found the resident's medication was already refilled and delivered to the facility on 04/23/25. LPA reviewed 5 staff files. 5 staff records observed complete to include health screening, TB result, personnel record, and fingerprint clearance. 2 out of 5 staff has an active 1st aid certification. 5 staff are provided annual training in compliance with Title 22 regulations. ADM is informed of a late/outstanding balance of the facility's annual licensing fee that was due on 04/13/2025. ADM was informed about the Department's Technical Support Program (TSP) as a resource for medication administration. ADM is familiar with the TSP website on cdss.ca.gov. Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Nicholas Inneh and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 24, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with Administrator (ADM), Nicholas Inneh. The purpose of the visit is to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on 10/23/2024. LPA discussed the non-compliance plan with the ADM to include ensuring that all staff are trained to provide resident care meeting physical, emotional, and social needs; plan for regular observation from the resident and documentation of resident functioning changes; ensuring the facility is kept clean, safe, sanitary and in good repair, addressing bed bugs proactively and promptly; ensuring all incident and death reports are documented and reported to CCL per Title 22; ensuring all staff obtain a criminal record clearance and association to the facility; ensure all residents medical assessments include a TB result prior to admission; ensure all resident’s reappraisals are updated annually; ensure all meals meet dietary and physician ordered nutritional requirements, and ensuring the Administrator provides proper oversight and administration of the facility operations in alignment with Title 22 regulations. During visit, LPA toured the facility with Administrator to include all the resident bedrooms, hallways, bathrooms, dining room, kitchen, and exterior. 3 staff members present were observed to be fingerprint cleared. 1 out of 3 staff members was not associated to the facility. During visit, the Licensee immediately associated the staff to the facility via Guardian website. See LIC809-C for additional information. LPA entered into all the resident bedrooms rooms with the ADM. There were no observation of bed bugs. ADM states the facility does not have any active cases of bed bugs. LPA observed staff actively cleaning the facility to include the resident bedrooms, bathrooms, and shower rooms during tour of the facility. Based on the facility's non-compliance plan it states that they will maintain a log for cleaning, maintenance, and pest control treatment. ADM states the cleaning and maintenance log has not been implemented yet but states a plan to implement the cleaning and maintenance log, ASAP. LPA observed bedroom #9 (vacant) and the shared bathroom in bedroom #9 was currently being remodeled. 2 staff files (S1 - S2) was reviewed. 2 out of 2 staff were provided training by a certified trainer to include topics of assisting resident with ADLs (activity of daily living), dementia care, and aging. ADM states they review the facility's policy regarding reporting requirements with the staff during the initial orientation. ADM was recommended to document training with the staff regarding topics listed in the non-compliance plan. Administrator stated understanding. Administrator states they have implemented regular check-in with staff every Friday for deep cleaning parts of the facility, monthly meeting with every staff, and daily meeting with the staff as part of their communication. 3 resident files (R1 - R3) was reviewed. 3 out of 3 residents are new admissions to the facility as of December 2024, January 2025, and February 2025. 3 out of 3 files contained a face sheet, TB result, updated appraisal/needs and services plan or the preplacement appraisal, and progress notes. The Administrator was advised regarding the importance of adhering to the facility's corrective action plan that was developed on 10/23/2024 to ensure the facility's stays within compliance of Title 22 regulation. No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided. This report was reviewed with Administrator, Nicolas Inneh and a copy of the report was emailed to the Administrator during visit.the state’s words, verbatim · CDSS document, Mar 4, 2025

Allegation investigated: Staff failed to prevent resident from being harmed by another resident Staff failed to safeguard resident's money

On 11/09/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with staff and explained the purpose of the visit. LPA learned that the Facility Designated Administrator (FDA) was unable to visit the facility at this time, however, LPA was able to contact FDA via phone and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current Census was 25. A brief interview with FDA Inneh was conducted. Allegation: Staff failed to prevent resident from being harmed by another resident. It was alleged that the staff failed to prevent resident from being harmed by another resident. During the course of this investigation, LPA conducted interviews and reviewed facility documentation. Based on interviews conducted it was learned that the facility conducted an internal investigation and found that there was no incident that involved R1 and R2 that was reported to the facility. Unsubstantiated An interview with R1 was conducted regarding this incident and LPA was unable to obtain additional information due to the lapse in time from the time of the incident to the visit conducted on 10/12/2024. An interview with 6 residents were conducted. 6 out 6 residents state that they have not been harmed by another resident or have seen any staff harm other residents around them. Based on records review, it was found that R2 has history of aggressive behavior however was not found to hurt other residents at the time of their residency at the facility. Based on the information gathered, it is unclear if the facility failed to prevent resident from being harmed by another resident. Allegation: Staff failed to safeguard resident’s money. It was alleged that the facility staff failed to safeguard resident’s money. During the course of the investigation, LPA conducted interviews and reviewed facility documentation. Based on interviews conducted it was learned that that facility does not currently manage any resident funds. It was found that many residents obtain Payee services in which they received their own money via mail or through debit services. A review of the facility records were conducted which confirm that the facility does not have a current surety bond to manage resident funding. An interview with 6 residents were conducted, 6 out 6 residents state that they have their own money and the facility does not handle any financial assets. Based on the information gathered, it is unclear if the facility staff failed to safeguard the resident’s money. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.the state’s words, verbatim · CDSS document, Nov 9, 2024 · control 26-AS-20230501121143

Allegation investigated: Facility did not follow a physician’s order for a special diet Resident was yelled at in the facility Resident did not feel safe at the facility

On 11/09/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with staff and explained the purpose of the visit. LPA learned that the Facility Designated Administrator (FDA) was unable to visit the facility at this time, however, LPA was able to contact FDA via phone and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current Census was 25. A brief interview with FDA Inneh was conducted. Allegation: Facility did not follow a physician’s order for a special diet It was alleged that the facility staff did not follow a physician’s order for a special diet. Based on interviews conducted it was learned that on 09/01/2023, R1 was sent out to the hospital due to consistent throat pain and was discharged with a blended diet. When R1 came back to the facility and their new diet was implemented, R1 refused to eat what was provided to them. Unsubstantiated The facility attempted to provide R1 other options however all R1 wanted was a small amount of rice and mashed potatoes as the resident’s throat continued to hurt. In addition, the facility conducted a care conference with the R1’s case manager to find the next steps to help support R1. Based on the information gathered, it is unclear if the facility did not follow a physician’s order for a special diet. Allegation: Resident was yelled at in the facility. It was alleged that facility residents were yelled at in the facility. During the course of this investigation, LPA conducted resident and staff interviews. Based on 3 staff interviews, it was denied that staff yelled at a resident in the facility. 3 out 3 staff members deny that they have witnessed any other staff members yelling at residents during their shifts. An interview with 5 residents were conducted, 5 out 5 residents state deny that they have been yelled at by staff members or any other residents. 5 out 5 residents deny that they have yelled at or have heard any other residents yell at each other. Based on the information gathered, it is unclear if the resident was yelled at in the facility. Allegation: Resident did not feel safe at the facility. It was alleged that the facility residents did not feel safe at the facility. During the course of this investigation, LPA conducted resident and staff interviews. Based on 5 resident interviews. 5 out 5 residents state that they feel safe at the facility. 5 out 5 residents state that staff make them feel safe and do not report any issues at this time. Based on the information gathered, it is unclear if the facility residents do not feel safe at the facility. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.the state’s words, verbatim · CDSS document, Nov 9, 2024 · control 26-AS-20230808140941

Allegation investigated: Staff did not prevent resident from making threatening comments towards another resident

On 11/09/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with staff and explained the purpose of the visit. LPA learned that the Facility Designated Administrator (FDA) was unable to visit the facility at this time, however, LPA was able to contact FDA via phone and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current Census was 25. A brief interview with FDA Inneh was conducted. Allegation: Staff did not prevent resident from making threatening comments towards another resident It was alleged that staff did not prevent resident from making threatening comments towards another resident. Based on interviews conducted the facility conducted an internal investigation and found that the staff member alleged to have stated a threatening denied that they make a threatening comment. It was learned that R1 would lie and would make inappropriate comments towards staff. Unsubstantiated An interview with 3 additional staff members were conducted. 3 out 3 staff members denied making inappropriate comments towards staff or hearing others make inappropriate comments. An interview with 5 residents were conducted. 5 out of 5 residents deny that staff make threatening comments towards others. Based on the information gathered, it is unclear if staff did not prevent residents from making threatening comments towards another resident. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.the state’s words, verbatim · CDSS document, Nov 9, 2024 · control 26-AS-20231218162242

Allegation investigated: Facility has bed bugs

On 11/09/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with staff and explained the purpose of the visit. LPA learned that the Facility Designated Administrator (FDA) was unable to visit the facility at this time, however, LPA was able to contact FDA via phone and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current Census was 25. A brief interview with FDA Inneh was conducted. Allegation: Facility has bed bugs It was alleged that the facility has bed bugs. During the course of this investigation, LPA conducted interviews and reviewed facility documentation. Based on interviews conducted it was learned that the facility was notified that there may be bed bugs in a residents room. The facility obtained pest control services as soon as they were notified and provided treatment. It was learned that the bed bugs were secluded in the residents room and did not spread into other parts of the facility. Based on the information gathered, the facility had bed bugs. The Department has investigated the above allegation and the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency is being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Administrator, Nicholas Inneh and a copy of the report and appeal rights were provided. Substantiated services. A review of R1’s records confirm that while the facility did charge the correct SSI/SSP Basic Service Rate, they did not charge R1 with the additional service rate of $13.98. Based on the information gathered, it is unclear if the facility is not adhering to SSI/SSP Basic Service Rate. Allegation: Facility does not keep grounds free of litter It was alleged that the facility does not keep grounds free of litter. During the course of this investigation, LPA conducted interviews and toured the facility. Based on interviews conducted, it was learned that the facility does have staff conduct housekeeping duties including but not limited to cleaning resident rooms, bathrooms, kitchen, mopping, disinfecting, and cleaning the outside surroundings. In addition, the facility conducts 2 hour rounds outside to ensure that facility grounds are free of any litter. LPA toured the facility on 10/12/2024 which included but were not limited to the kitchen, resident rooms, bathrooms, and outside grounds. During the course of this visit LPA did not find any indication that the facility does not keep grounds free of litter. The outside area also had a designated area for smoking purposes in which cigarette buds were ensured to be disposed of in the designated area. Based on the information gathered it is unclear if the facility does not keep grounds free of litter. Allegation: Facility does not have sufficient staff to provide care to the residents It was alleged that the facility does not have sufficient staff to provide care to the residents. During the course of this investigation, LPA conducted interviews and reviewed facility documentation. Based on interviews conducted with 3 staff. 3 out 3 staff state that they believe that they have sufficient staff to provide care to the residents. An interview with 5 residents was conducted. 5 out 5 residents deny not being able to obtain help from staff. 5 out 5 residents state that they do not have any issues with the care that they obtain from the staff. In addition, LPA reviewed facility records that show that they have at minimum 3 staff members and a medication technician on site to provide care and supervision on site at all times. Based on the information gathered it is unclear if the facility does not have sufficient staff to provide care to the residents. Allegation: Facility does not provide the residents with basic services to include hygiene items It was alleged that the facility does not provide the residents with hygiene items. During the course of this investigation, LPA conducted interviews and reviewed facility documentation. Based on interviews conducted, staff denied that they do not provide residents with hygiene items. It was found that hygiene items were stored at the facility which included but were not limited to, body soap, shampoo, conditioner, toothbrushes, and toothpaste. Many times family members will provide the facility with additional supplies such as electric shavers to help assist with their loved ones at the facility. An interview with 5 residents was conducted. 5 out 5 residents deny that they have to provide their own hygiene items. 5 out 5 residents state that the facility provides everything for them. In addition, LPA reviewed facility storage and found that the facility houses hygiene supplies. Based on the information gathered it is unclear if the facility does not provide the residents with hygiene items. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.the state’s words, verbatim · CDSS document, Nov 9, 2024 · control 26-AS-20240117134530

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80087(a)(1) · Plan of correction due date: Nov 9, 2024

80087(a)(1) (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects. This is not met as evidenced by: The licensee did not ensure that the facility was free of pests such as bed bugs. It was learned that upon admission the resident room obtained bed bugs and was treated upon notice. This poses a potential health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Nov 9, 2024

Plan of correction: Licensee has obtained pest control services. POC has been cleared as of this date.

Allegation investigated: Staff yelled at resident Staff used inappropriate language with resident

On 11/09/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with staff and explained the purpose of the visit. LPA learned that the Facility Designated Administrator (FDA) was unable to visit the facility at this time, however, LPA was able to contact FDA via phone and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current Census was 25. A brief interview with FDA Inneh was conducted. Allegation: Staff yelled at resident It was alleged that facility staff yell at resident. During the course of this investigation, LPA conducted resident and staff interviews. Based on 3 staff interviews, it was denied that staff yelled at a resident in the facility. 3 out 3 staff members deny that they have witnessed any other staff members yelling at residents during their shifts. An interview with 5 residents were conducted, 5 out 5 residents state deny that they have been yelled at by staff members or any other residents. 5 out 5 residents deny that they have yelled at or have heard any other residents yell at each other. Based on the information gathered, it is unclear if the staff yelled at a resident. Unsubstantiated Allegation: Staff used inappropriate language with resident It was alleged that facility staff used inappropriate language with resident During the course of this investigation, LPA conducted resident and staff interviews. Based on 3 staff interviews, it was denied that staff used inappropriate language with the resident in the facility. 3 out 3 staff members deny that they have witnessed any other staff members using inappropriate language with residents during their shifts. An interview with 5 residents were conducted, 5 out 5 residents state deny that staff use inappropriate language with them. 5 out 5 residents deny that they have yelled at or have heard any other residents use inappropriate language with each other. Based on the information gathered, it is unclear if the staff used inappropriate language with the resident. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.the state’s words, verbatim · CDSS document, Nov 9, 2024 · control 26-AS-20231020085113

Allegation investigated: Staff did not notify Resident Representative of resident's change in health insurance carrier. Facility is not assisting resident with medical care.

On 10/30/2024, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator Nicholas Inneh and LPA explained the purpose of the visit. Regarding the allegation of Staff did not notify Resident Representative of resident's change in health insurance carrier and facility is not assisting resident with medical care, reporting party (RP) stated that when resident (R1) turned 65, RP signed R1 up for Medicare and had also signed up for Santa Clara Family Health Plan. Without informing RP, Director (S1) signed R1 up for another insurance provider (Anthem). RP had no idea until he/she received a letter from Santa Clara Family Health Plan stating that R1 was "cut off". RP discovered that S1 had signed R1 for Anthem in April of 2021, without consulting RP. After RP found out, RP signed R1 up again with Santa Clara Health Plan and S1 got upset with RP and is now refusing to help with getting R1 medical treatments, setting up and take R1 to doctor's appointments. page 1 of 2 Unsubstantiated LPA Ng interviewed RP and confirmed the story that was provided on the initial complaint. LPA was able to interview S1 and it was stated that the facility used a different insurance, an in-house medical insurance provider. RP stated R1's insurance got changed without any apparent reason. S1 tried to fix it, and later found that a family member (F1) changed the insurance without notifying S1 and the staff. F1 somehow told S1 that he/she wanted to use some other insurance. S1 explained to F1 that if he/she used some other insurance, then R1 could not use the insurance, that sent physician and nurse to the facility. If R1 used other insurance, then R1 had to travel to clinic or hospital to receive medical assistance. It would not be ideal since R1 was in wheelchair, that R1 might have to travel by taxi to see the doctor. That was why S1 tried to persuade F1 to use the insurance instead. There was no lapse that R1 did not have a time that there was no insurance to receive medical assistance. LPA Ng also interviewed three residents. Two out of three (R2 & R3) mentioned that they had no problem with insurance that it was not changed. R1 stated he/she was not aware that the insurance was changed or his/her representative not being notified. For the residents medical care, R1 stated he/she saw the doctor recently but did not have any note from the doctor. R2 stated he/she got assisted getting medical care from the facility. R3 stated he/she had his medical visit about 2 weeks ago and also got medicine prescribed. A staff member (S2) was also interviewed and stated that if a resident did not have insurance, the facility would help that resident to find one. So no insurance, no issue. S2 also shared that he/she was not aware of any resident not being assisted in the facility because of insurance or any other kind of problem. Based on interviews, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. page 2 of 2 When S1 was interviewed, S1 stated he/she had every residents' money including R1's money in his possession. S1 mentioned that F1 stopped sending money to R1 recently. R1 currently used the Life Freedom Card that was managed by BMC (Benefits Management Corporation) to buy the things R1 needed. According to the LIC 405 (Record of Client’s/Resident’s Safeguarded Resources) for R1, the logs shows that from 10/9/2017 to 1/11/2019, R1 was receiving $100. Starting from 2/14/2019 to 7/20/2021, different amounts have been received ranging from $37-$161. This was also audited by LPA Ng and it didn’t have any discrepancy. The document also shows how much money was given to R1 upon request and countersigned by S1 and R1. Based on interviews & records review, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. Report is reviewed and copy is provided. page 2 of 2the state’s words, verbatim · CDSS document, Oct 30, 2024 · control 26-AS-20210817095116

Type of visit: Office

On 10/23/2024 San Bruno Regional Office - San Jose Unit conducted a non-compliance conference meeting with Licensee Cyril Inneh and Administrator Nicholas Inneh. Present in the meeting were Regional Manager Vivien Helbling, Licensing Program Manager Jackie Jin, and Licensing Program Analyst Christine Dolores. During the non-compliance meeting, the following serious violations were discussed: 87411(a) Personnel Requirements – General, 87466 Observation of the resident, 87303(a) Maintenance and Operations, 87211(a)(1)(A) Reporting Requirements, 87355(e)(2) Criminal Record Clearance, 87458(b)(1) Medical Assessment, and 87405(d)(2) Administrator - Qualifications and Duties. During this meeting, the compliance plan was developed and discussed with the licensee which includes more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations: https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers. During this meeting, the LIC809 and LIC809D from 10/22/2024 was amended and report was provided to the Licensee and Administrator. This report was reviewed with Licensee Cyril Inneh and Administrator Nicholas Inneh and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 23, 2024

Allegation investigated: Licensee is not ensuring that facility is kept free of rodents

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open the initial complaint investigation. LPA met with Administrator, Nicholas Inneh. On 10/21/2024, the Department received the complaint. On 10/22/2024, the initial complaint investigation was conducted. Documents were obtained to include the LIC500, resident roster, a resident's progress notes, and the facility's policy. It was alleged that the licensee is not ensuring the facility is kept free of rodents as a resident has seen mice in the facility for the past month. On 10/22/2024, 3 staff members were interviewed. Based on staff interview, S1 states there were 2 residents who informed S1 of the observation of either a mouse or rat in their bedroom. S1 was first made aware of a rat inside resident (R1)'s bedroom on 10/10/2024. After S1 was made aware, S1 searched R1's room and did not observe any rodents or rodent droppings. Page 1 of 2. Unfounded Page 2 of 2... S1 placed sticky traps inside R1's bedroom. S1 reminded the residents to not eat or store food in their rooms and to take out the trash to prevent rodents from entering in the facility. S1 states R1 did not complain of any observations of a rat inside R1's bedroom since 10/10/2024. S1 was made aware a second time of a mouse inside resident (R2)'s bedroom on 10/18/2024. S1 states to have spoken with R2 and cleaned out R2's bedroom to include underneath R2's bed, clothes and trash. S1 did not locate any rodent. S1 states R2 did not mention anything to S1 sooner. S1 states they did not yet contact a pest control company and had plans to contact a pest control company today (10/22/2024). S1 states on 10/21/2024, the police were called to the facility regarding a rat infestation. S1 stated they police inspected the facility and left. S1 denied a rat infestation. On 10/22/2024, 2 residents were interviewed. Based on resident interview, R1 stated that the facility staff has placed sticky traps in the facility. R1 states that they also asked him/her to clean out his/her closet and reminded the residents to not eat in their room. R2 stated that the staff have placed sticky traps in the kitchen and have cleaned out their room. R2 states that the staff have also reminded the residents that they cannot eat in their rooms. On 10/22/2024, LPA Dolores entered into R1 and R2's bedroom and did not observe any rodent or rodent droppings. LPA Dolores entered the kitchen and observed sticky traps inside the pantry. Based on staff interview, 2 out of 2 staff denied the observation of mice or rats in the facility and kitchen area. 2 out of 2 staff stated the sticky traps were placed about 2-3 weeks ago and there were no mice or rats that were found on the traps. The Department has investigated the above allegation. Based on interview and observation, the above allegation is unfounded meaning the allegation is false, could not have happened and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Nicholas Inneh and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 22, 2024 · control 26-AS-20241021095103

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Christine Dolores and Simi Rai arrived unannounced to conduct a case management visit to follow-up on a visit from 11/02/2023. The visit was regarding an incident that occurred at the facility on 10/12/2023 pertaining to resident (R1). LPAs met with Administrator, Nicholas Inneh. On 10/12/2023, staff (S1) noticed R1 was choking on food during dinner time. During the investigation, staff members were interviewed. Based on staff interview, it was stated that S1 was facing the TV during dinner time. S1 initially heard someone say something but ignored it at first, as S1 thought it was nothing. The second time, a resident yelled out for help as R1 was choking on food. S1 immediately performed CPR. See LIC809 on 01/16/2024 for additional information. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Nicholas Inneh and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, May 13, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 14, 2024

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by: Based on interview, record review, and observation staff (S1) was not competent in providing proper supervision during dinner time by having his/her back turned towards the residents and initially ignoring the resident the first time when R1 began to choke, which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 13, 2024

Plan of correction: Licensee will provide staff training with emphasis in supervision. Licensee will submit the training document via email to LPA Dolores by POC due date.

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Christine Dolores and Simi Rai arrived unannounced to conduct a case management - other visit. LPAs met with Administrator (ADM) Nicholas Inneh. The purpose of the visit is to hand deliver an exclusion letter for staff member (S1). The letter was handed to the Administrator. Staff (S1) was present during visit. LPA Dolores explained the exclusion letter to S1. S1 refused to take the letter. S1 was immediately released from work. LPAs observed another staff (S2) replace S1. No deficiencies were cited today per California Code of Regulations, Title 22. This report was reviewed with Administrator, Nicholas Inneh and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 13, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - other visit. LPA met with Administrator (ADM), Nicholas Inneh. During visit, LPA obtained photographs of the facility's dining room area using LPA's state issued cell-phone. LPA obtained a copy of a staff member's CPR certification. LPA interviewed 1 staff member. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Nicholas Inneh and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 18, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with Administrator (ADM), Nicholas Inneh. LPA entered and observed 15 bedrooms, 2 shower rooms, 1 common bathroom, dining room, kitchen, medication room, and exterior. All fire exit routes were free and clear of obstruction. All staff present are fingerprint cleared. Facility temperature maintained between 69 to 71 degrees Fahrenheit. Facility's hot water temperature maintained at 119 degrees Fahrenheit. Resident bedrooms contains lighting, beds, linens, dressers/closet space, and a night stand. LPA observed the facility has additional linens available for the residents. Facility has at least 7 days worth of non-perishables and 2 days worth of perishable foods. Items in the refrigerator and freezer observed covered. LPA advised to place a thermometer inside the refrigerator and freezer to monitor the temperatures to ensure compliance with Title 22 regulations. Fire extinguisher last services on 04/13/2023. Carbon monoxide detectors present throughout the facility. The facility has a scheduled date to service all fire extinguishers and carbon monoxide detectors. Emergency disaster plans and facility exit routes posted at every exit door. Last emergency drill was conducted on April September 2023. Facility was advised. LPA reviewed 6 resident files. LPA observed 2 residents physician's report were dated in 2016 and 2020. 1 residents physician's report was not on file. Administrator was advised. LPA reviewed 6 residents centrally stored medical records and 6 residents P&I money is maintained. 6 residents were interviewed. SEE LIC809-C. LPA reviewed 4 staff files to include 1st aid certification, health screening, TB result, and personnel record. LPA did not observed staff are provided 20 hours of annual training on topics to include but not limited to dementia, postural supports, restricted health conditions, and hospice. Administrator was advised. Facility did not have an infection control plan available for LPA's review. LPA requested for the facility's updated LIC500, infection control plan, and liability insurance by 04/19/2024. Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Nicholas Inneh and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 18, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christine Dolores arrived at the facility unannounced to conduct a case management visit to follow-up on a visit from 11/02/2023. The visit was regarding an incident that occurred at the facility on 10/12/2023 pertaining to resident (R1). LPA met with Administrator, Nicholas Inneh. On 10/26/2023, LPA Dolores visited the facility unannounced and was made aware of a resident (R1) who passed away. Based on investigation, it was found that on 10/12/2023, staff noticed R1 was choking on food during dinner time. Staff immediately called 911 and began CPR and First Aid (Heimlich Maneuvers) until the paramedics arrived. R1 was transported to the hospital and pronounced deceased on 10/13/2023. Based on record review, R1’s cause of death was due to lack of oxygen to the brain from choking on food. It was also noted that R1 had a throat condition. Based on staff interview, for dinner that night R1 was served a chicken burrito that was cut into three pieces by the staff. R1 was provided a regular diet. It was stated by staff that R1 has had a history of choking on food. Prior to R1’s passing, staff did observe something in R1’s throat. The observation was stated to be brought to the attention of the Administrator. The staff also informed R1’s doctor, however, R1’s doctor did not provide a change of order to R1’s diet. Based on review of records, there is no documentation of the staff’s observation regarding R1’s throat condition. There is also no documentation that R1 was seen by the doctor in the year 2023 regarding R1’s throat condition. SEE LIC809-C. The review of R1’s records showed that R1 was at the hospital in October 2020, and it was noted R1 was diagnosed with a throat condition. In the discharge summary, it was noted there was an order for small portions. Based on interview, it was stated that during that time, R1 was being fed a regular diet. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. An immediate civil penalty of $500.00 is being assessed against the facility today for violation resulting in the death of a resident in care. An additional Civil Penalty for a violation resulting in the death of a resident is pending review. A plan of correction was developed with the Administrator, Nicholas Inneh. A copy of the report and appeal rights were also provided to the Administrator, Nicholas Inneh.the state’s words, verbatim · CDSS document, Jan 16, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jan 17, 2024

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not ensure to document the observation of resident (R1)’s throat condition resulting in R1’s death after choking on food which poses/posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 16, 2024

Plan of correction: Licensee will provide an in-service training to all the staff regarding observations of the residents and proper documentation regarding any changes in condition. Licensee will submit the in-service training to LPA by POC due date of 01/17/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87555(b)(10) · Plan of correction due date: Jan 17, 2024

(b) The following food service requirements shall apply: (10) Where indicated, food shall be cut, chopped or ground to meet individual needs. This requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not ensure to cut R1’s foods into small portions as indicated on his/her medical discharge summary which poses/posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 16, 2024

Plan of correction: Licensee will provide an in-service training with all the staff on portion sizes and reviewing physician's orders / discharge summaries relating to residents special diets. Licensee will submit the in-service training to LPA by POC due date of 01/17/2024.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - other visit. LPA met with Administrator, Nicolas Inneh. During visit, LPA delivered an amended report for complaint control number 26-AS-20231101121001. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Nicolas Inneh and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 14, 2023

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - other visit. LPA met with Administrator, Nicolas Inneh. During visit, LPA interviewed 1 staff member regarding a death report the Department received for resident (R1). No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Nicolas Inneh and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 14, 2023

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - other visit. LPA met with Administrator, Nicolas Inneh. During visit, LPA advised the facility regarding the use of their video surveillance system in the common areas. Based on interview, the Administrator states they are unsure where the video footage are being stored and who has access to the video surveillance system. It was stated that the video surveillance system was already implemented prior to the Administrator start at the facility in 2022. The individual who may have knowledge of the video surveillance system does not work in the facility and the facility does not have contact to the individual. Based on observation, the video surveillance monitors different locations of the facility to include the hallways, kitchen, dining room, and parking lot. The location of the video surveillance monitor is in the Administrator's office. LPA observed the video surveillance does not have audio component. The Administrator states plans to install another video surveillance system only in the facility's common areas by next week. The new video surveillance system will include access to the video files. LPA advised to disconnect the video surveillance unless the facility knows where the video surveillance records and files are being stored. No deficiencies are being cited per California Code of Regulations, Title 22. Advisory note provided. This report was reviewed with Administrator, Nicholas Inneh and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 14, 2023

Allegation investigated: Staff do not properly maintain the facility grounds

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open the initial complaint investigation. LPA met with Administrator, Nicholas Inneh. On 11/01/2023, the Department received a complaint alleging the staff do not properly maintain the facility grounds. On 11/02/2023, the intial complaint investigation was conducted. During visit, LPA toured the facility with the Administrator (ADM) to include 15 resident bedrooms, resident bathrooms, 1 shower room, dining room, kitchen, medication room, hallways, and exterior. Based on observation, LPA observed spider webs along the walls and ceiling of the hallways and resident bedrooms. The resident bedrooms were not properly clean and contained dust and dirt along the walls, base boards, windows, and floors of the bedrooms. Resident bedrooms floors contained missing and/or broken tiles. SEE LIC9099-C. Substantiated LPA observed the floors of the resident’s bathrooms contained dark grey stains and black spots. ADM states the bathroom tiles are old and may be stained. ADM sprayed one of the bathroom floors with a cleaning solution and was unable to wipe off the dirt. ADM was able to remove certain dirt marks surrounding the floor of the toilet. The walls of the bathrooms observed with open patches, dirt and dust. LPA observed 2 light fixtures that were broken along the hallways. Based on interview and record review, the Licensee has plans to renovate the facility’s grounds to include (but not limited to) updating all the damaged walls, paint, doors, floors, fence, and parking lot. Licensee is currently in the process of obtaining possible funding from the county to assist with the facility's upcoming renovations. Licensee emailed the letter from the county to LPA Dolores. The Department has investigated the above allegation and the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency is being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Administrator, Nicholas Inneh and a copy of the report and appeal rights were provided. LPA and ADM entered into 15 resident bedrooms. LPA observed 1 out of 15 rooms had an obvious black marking in the corner of the room. The corner of RM #4 had a black marking next to the resident’s bed. Due to the resident laying in bed sleeping during inspection, LPA was unable to closely observe the black marking in the corner of the room. LPA was unable to determine if the black marking was due to mold, dirt, or cracks in the wood. During the tour of the remainder of the bedrooms, LPA did not observe any obvious mold in the facility. Based on interview with the Administrator, the Administrator has not observed nor was made aware of any mold growing in the facility. ADM states the black marking may be due to the resident touching that area. LPA advised Administrator to have the corner of RM #4 professionally inspected to ensure the area does not have mold. Administrator stated understanding. The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unsubstantiated. An unsubstantiated finding indicates that although the allegation may have happened and/or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided. This report was reviewed with Administrator, Nicholas Inneh and a copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 2, 2023 · control 26-AS-20231101121001

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Nov 3, 2023

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not ensure the facility was clean, sanitary and in good repair which poses/posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 2, 2023

Plan of correction: Licensee will purchase new light fixtures for the facility by 11/03/23. Licensee will go over in-service training with staff regarding proper cleaning. Licensee will submit the completed in-service training document and light fixture receipt to LPA Dolores by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christine Dolores arrived to the facility unannounced to conduct a case management – incident visit regarding an incident that occurred at the facility on 10/12/2023. LPA met with Administrator, Nicholas Inneh. On 10/26/2023, LPA Dolores was made aware of a resident (R1) who passed away. On 10/12/2023, staff noticed that R1 was choking on food and immediately called 911 and began CPR and First Aid (Heimlich Maneuvers). R1 then lost consciousness and staff began chest compressions until EMT arrived. R1 was transported to the hospital and pronounced deceased on 10/13/2023. Based on interview and review of R1’s records, R1 did not have a special diet. For dinner that night, the residents were served chicken burritos. ADM states the resident did not have any issues with swallowing food or medical conditions regarding his/her throat. ADM is not aware of any history of R1 choking on food. After the incident, the ADM immediately informed R1's case manager, conservators, and physician. The staff who provided CPR has an active CPR/First Aid Certification. ADM stated on the morning of 10/13/2023, R1's case manager arrived to the facility and informed the facility staff that R1 had passed away at the hospital. LPA requested for R1’s death certificate. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Nicholas Inneh and a copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 2, 2023

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Christine Dolores arrived to the facility unannounced to open an initial complaint investigation. During the complaint investigation, a case management - deficiencies visit was conducted. LPA met with Administrator (ADM), Nicholas Inneh. During visit, LPA was made aware of a resident (R1) who passed away. Based on interview with ADM, the resident passed away on 10/13/2023. LPA did not observe an incident report and death report was sent to the Department. LPA spoke with the Licensee, Cyril Inneh during visit who states he had faxed the incident report and death report the day after the incident. Licensee was unable to immediately provide the proof of fax during visit. The following documents were obtained to include the incident report, death report, police case number, R1's physician's report, appraisal/needs and services plan, identification and emergency information, and medical records. Licensee will submit staff's 1st Aid Certification to LPA Dolores by 1:00pm today. A deficiency was cited per California Code of Regulation, Title 22. See LIC809-D. A civil penalty of $250 will be assessed for a repeat violation within 12 months of the initial citation. If the deficiency is not corrected within 24 hours, an additional $100 will be assessed until the deficiency is corrected. See LIC421FC. This report was reviewed with Administrator, Nicholas Inneh and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Oct 26, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Oct 27, 2023

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, … : (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. … (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.This requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not ensure to inform the Department of a death of a resident within 7 days of the occurrence which poses/posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 26, 2023

Plan of correction: Licensee will submit a plan in writing to ensure incident reports and death reports will be sent to the Department within the reporting requirement, to LPA Dolores by POC due date.